Client Weekly Update Client Name* First Last Primary Counselor*Select your counselor hereJay GoldMikare MichiraRachael CavegnRashad HameedRosmarie DauthVictoria ReesmanOtherTREATMENT DETAILSAre you in a recovery residence?* Yes No Which one? Move-in Date:* MM slash DD slash YYYY SUBSTANCE USE & WITHDRAWAL ASSESSMENTHave you consumed any of the following substances since your last update?*Check all that apply None Alcohol Marijuana Benzodiazepines Heroin Opiates/Opioids Methamphetamine Ritalin/Adderall/Etc Cocaine Molly/MDMA Inhalants Salvia LSD/Hallucinogens Synthetic Cannabis Bath Salts/Cathinones Kratom Steroids DXM/Cold Meds GHB Methadone Suboxone/Subutex Pseudoephedrine Caffeine Nicotine Other OTC Meds Other Substance Are you currently receiving medication assisted treatment?* Not on MAT On Methadone On Suboxone Other MAT What is your current dose?* How long have you been at this dose?* Please describe any withdrawal symptoms you may be experiencing: PHYSICAL HEALTH & WELLNESSPlease rate how physically “well” you have felt this week:* Great Good Just Ok Not Good Awful Explain: Any new medical/health issues?* Yes No Describe: Sleep Quality?* Great Good Just OK Not the Best Awful How many hours per night?* How many regular, quality meals do you eat on an average day?* 1 2 3 4 or more Do you want to meet with a nutritionist?* yes no Any appointments this week?* Yes No What/When? Did you have any Medication changes this week?* Yes No What/When?* What are you doing for Physical Activity?* EMOTIONAL, BEHAVIORAL & MENTAL HEALTHWhat was your biggest accomplishment this week?* Have you had any thoughts of self-harm this week?* No Yes Have you acted on any thoughts?* No Yes Please talk to a staff member as soon as possible!Rate your overall mood this week:* Great! Good! Just Ok Pretty Bad Awful Rate your overall stress level this week:* Very Little A Little Medium Too Much! Extreme! Biggest stressors this week:* What two coping skills have you used this week? friend family recovery coach fact checking self soothing self care TIPP DEARMAN mindfulness peer support asking for help recreation exercise sticking to a routine cleaning cuddling with a pet other RECOVERY MOTIVATION AND PARTICIPATIONWhat group did you enjoy the most?* Nutrition Mental Health Primary Counselor Gender Specific Group Make-up Group What is your primary motivation for being in recovery/treatment?* My Own Goals/Health Probation/Courts Child Protection Housing Family/Partner Something Else Please tell us how excited you've been to do the following activities this week:Treatment Group:*Attending and Sharing in Group Very! Excited! So-So Ugh! Noooo! Other Treatment Appointments:*Individual Counseling, Therapy, Peer Support Very! Excited! So-So Ugh! Noooo! Other Recovery Activities:*Recovery Meetings, House Meetings, Probation Very! Excited! So-So Ugh! Noooo! What is your main goal right now?* RELAPSE PREVENTION/RECOVERY MANAGEMENTHow confident have you felt in your recovery/sobriety?* Extremely Confident Very Confident Somewhat Confident Not Very Confident Not at All Confident Please identify any triggers that you’ve experienced this week:*Check all that apply Select All Using Friends Family Members Partners/Spouses Bars/Clubs Old Neighborhoods Seeing Drugs/Alcohol Social Situations Celebrations Dining Out Movies/TV Sexual Encounters Money Holidays Ads/Marketing Stress Sadness Depression Frustration/Anger Irritability Dishonesty Loneliness Overconfidence Guilt/Shame Self-Loathing Discrimination/Prejudice Legal Issues Negative Thoughts Fear of Failure Wanting to Feel High Wanting to Feel Better Criminal Thrill-Seeking Longing for the Old Lifestyle Wanting to Belong Other: Have you been having trouble with any of the following behavioral challenges?*Check all that apply Overeating Restricting Food Binging/Purging Sexual Behavior Spending/Shopping Gambling Video Games Repetitive Behaviors Compulsions/Obsessions Cutting/Self-Harm Compulsive Cleaning Excessive Exercising Hair Pulling/Skin-Picking Other Compulsive Behaviors None of the Above RECOVERY ENVIRONMENT, RELATIONSHIPS & SUPPORT NETWORKHow many supportive relationships do you currently have?* 15+ 10+ 5+ A handful None Who do you consider your primary support presently?* How often do you call/text/chat with your support network?* Daily 2+ x/Week Weekly When Needed Not Often How often do you spend face-to-face time with your support network?* Daily 2+ x/Week Weekly When Needed Not Often How often do you attend mutual/recovery support groups?* Daily 2+ x/Week Weekly When Needed Not Often Do you have a sponsor/recovery coach?* Yes No Working on it How often do you talk to them? Rate how “connected” you feel to others around you:* Very Quite Just Ok Not Very Not at all What are you doing for fun/recreation?* How are things with your sober house leader/peers?* Great Good Ok Not the Best Awful N/A Do you have any probation/court/CPS meetings coming up?* No Yes N/A Details:* Are you following all of your legal requirements?* No Yes N/A If it applies, how is work/school going for you?* Great Good Ok Not the Best Awful N/A Please rate your relationship with your counselor:* The Best Pretty Good Just Ok Not the Greatest Terrible What can they do to improve the relationship?* What can you do?* What do you like most/least about this program?* What would make the program better?* Anything else you’d like us to know? Δ
